CBT Today Commentary

What does contemporary CBT look like?

“Meaning provides the richness of life; it transforms a simple event into an experience.” (Beck, 1976, p. 47)

The essence of Cognitive-Behaviour Therapy (CBT) is that human beings are meaning makers; we need to make meaning of our internal and external world. It is the meaning we give to ourselves, our thoughts and feelings, other people, the day-to-day situations we find ourselves in, and the future, that determines our experience – either good or bad.

It is 54 years on since Aaron Beck first proposed that thinking plays a causal role in emotional disorders; sparking the birth of CBT. He initially proposed this to be the case for depression, and then over the years this thesis has branched out to encompass all types of psychopathology.

CBT has certainly stood the test of time. Current clinical guidelines typically recommend CBT as the treatment or one among a number of treatments, that practitioners should be providing as first-line interventions to their clients, for a range of different problems.

Lucky for me, CBT is an approach that resonates with me and that I would naturally choose to practice with my clients, so I have no problem with such guidelines. However, think of clinicians for whom CBT isn’t necessarily their first treatment choice, and no wonder CBT today is at times met with some animosity.

I know that some clinicians and clients view CBT as a very dry, verbal, emotionless, intellectual exercise, where the therapist passes the client a pre-prescribed worksheet with any number of columns on it; the exact number depending on which of the hundreds of CBT workbooks it is taken from. The therapist then debates and challenges the client’s thinking, or when the client has graduated in therapy enough, the client debates and challenges their own thinking. The only victory being when the worksheet is complete and the clients “faulty”, “erroneous”, “dysfunctional”, or “maladaptive” thoughts (whichever pejorative label you fancy), have been corrected.

This is not the CBT I know or have practiced over my career, and if you return to some of Beck’s early writings, I don’t think this is the type of CBT he meant either. I would argue that this is a very simplistic view of what CBT has to offer our clients. I would argue that this is what CBT looks like when practiced poorly.

In addition, today it seems misleading to talk about CBT as a unitary construct. Instead, it is more appropriate to talk about “CBTs” (i.e., Cognitive Behaviour Therapies; Menin, Ellard, Fresco & Gross, 2013, p. 234). These days CBT really refers to a “family of clinical interventions” (Menin et al., 2013, p. 234). Beck’s original Cognitive Therapy is clearly most synonymous with CBT, however there have been numerous approaches, variations, and distinct models developed for different disorders, and ways in which CBT has changed in its emphasis and technology since the 1960’s. Clinicians have started to talk about “traditional CBTs” and “recent CBTs” (Menin et al., 2013, p. 235), and under the later umbrella have placed therapies such as Acceptance and Commitment Therapy (ACT), Dialectical Behaviour Therapy, Mindfulness Based Cognitive Therapy, Behavioural Activation, the Unified Protocol, Motivational Interviewing, Compassion Focused Therapy (Menin et al., 2013, p. 235), and I would add Metacognitive Therapy, to name just a few.

Some may argue that this makes CBT too inclusive, and that any new therapy that demonstrates some efficacy or effectiveness, can be snapped up by CBT and claimed as its own. However, given CBT has evolved so much since the 1960s, it is worth asking the question: what makes a therapy legitimately fall under the umbrella of CBT? Today, what makes CBT, CBT?

What is core and consistent across any CBT, is that unhelpful cognitions and cognitive processes are placed in a central causal role in the cognitive-behavioural formulation of the client’s emotional difficulties. As such, these unhelpful cognitions and cognitive processes are the main focus of the formulation driven treatment that follows.

The technology available to clinicians for addressing unhelpful cognitions and cognitive processes has grown significantly over time (e.g., imagery rescripting, mindfulness, defusion, self-compassion strategies, etc). Also, don’t forget the key role that behavioural methods (i.e., behavioural experiments, behavioural activation, etc) have always played as a powerful experiential vehicle to cognitive change.

Also, the types of cognitive changes we are aiming for in our cognitive-behavioural formulations have also expanded over time. Instead of just questioning thoughts about a situation we find ourselves in, or going into more depth and modifying pervasive core beliefs, today we may be addressing beliefs about thinking itself. For example, helping clients to discover that their thoughts “aren’t facts, often aren’t important, don’t help or harm them, and don’t need to be listened to or taken seriously”. This cognitive shift is a direct target in metacognitive therapy, and a key learning that emerges from ACT and mindfulness-based therapies.

Similarly, we may be attempting to address beliefs about emotion itself. For example, we might be helping clients discover that they “can tolerate or accept emotional discomfort, can ride the wave of emotion, can handle and cope with their feelings rather than escaping them, and that these feelings are temporary and they can just watch them come and go”. Again, this is a key message to emerge from ACT and other therapies that include mindfulness-based practices.

The two above examples both demonstrate important cognitive shifts that many clients need to make during therapy. Both involve modifying beliefs that play an important role in perpetuating a client’s suffering (i.e., beliefs about thinking and beliefs about emotions). Both are things that CBT is often criticised as neglecting, but I would argue that today these are things that CBT should not and does not neglect.

Even in the early days, Beck acknowledged that there were many methods for getting to the same cognitive point. He left the door open in CBT, such that any technique that evidence demonstrates can facilitate helpful cognitive change, can be a part of CBT. That is, as long as it is done in the service of addressing an important aspect of the cognitive-behavioural case formulation. And that is the key to CBT today…the cognitive-behavioural case formulation.

As an example, I use many aspects of ACT in my clinical work, and I think that ACT has a great deal to offer, yet I call myself a CBT practitioner. I think it would be misleading to call myself an ACT practitioner specifically. Why? Because all the elements I use from ACT are in the service of modifying unhelpful cognitions or cognitive processes that are formulated as central to maintaining the client’s emotional difficulties. And that’s CBT.

So, what should ‘contemporary CBT’ look like in real world clinical practice today?

My hope is that CBT is a creative and collaborative process between therapist and client, working together to discover what cognitions are most problematic for the client (i.e., cognitions about a specific situation, the self, one’s thoughts or feelings, other people, the world, the future, etc). We then select based on therapist skill and client preference, from the various evidence-based methods available for addressing these cognitions for the better. Attention is paid to the best way to present these methods to the client, so they really resonate with the client, and are embraced and applied in their daily life. And of course, the outcomes of the methods used are monitored to ensure that the work we are doing in therapy is effective.

CBT is about figuring out which evidence-based strategies are most effective in helping a client learn what they need to learn, to better their overall emotional well-being and quality of life. In doing this we can select from various evidence-based technology such as: thought records (with a strong emphasis on imagery-based cognition); behavioural experiments; behavioural activation; breathing retraining; situational, imaginal and interoceptive graded exposure; worry postponement; metacognitive challenging and behavioural experiments; defusion or what I call cognitive detachment strategies; mindfulness-based attention retraining; imagery rescripting; self-compassion strategies; metaphorical coping imagery; positive imagery; distress tolerance strategies; and so on.

In summary, CBT today is about staying true to a cognitive-behavioural formulation driven treatment. The exact technology used in the treatment is up to you, your client, and the evidence.